Consolata Rehab And Wellness Center On The Teche

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to obtain ordered medications from the pharmacy for 1 (Resident #73) of 5 residents observed during medication administration.Findings:Review of Resident #73's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes mellitus without complications, paranoid schizophrenia, and essential (primary) hypertension.Review of Resident #73's current physician orders revealed an order, dated 06/01/2026, for Farxiga oral tablet 10 mg, give 1 tablet by mouth one time a day related to type 2 diabetes mellitus without complications.On 06/09/2026 at 8:50 a.m., an observation was made of S10LPN during morning medication administration. S10LPN administered all of Resident #73's medications except for his Farxiga oral tablet 10 mg (milligram). S10LPN stated the Farxiga was ordered last Monday (06/01/2026) but they still had not received it from the pharmacy. She was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and policy review, the facility failed to appropriately store over the counter (OTC) medications in the locked medication cart.Findings:On 06/08/2026 at 9:33 a.m., an observation was made of an unattended medication cart on Hall B. A bottle of Aspirin 81 mg and a bottle of Geri-Kot 8.6 mg were observed unattended on top of the cart. Two residents walked by the parked cart. S10LPN returned to the cart after 5 minutes and confirmed that she had left the medications on top of the cart and stated that she should have placed the meds in the locked cart.On 06/10/2026, a review of the facility's policy titled Medication Labeling and Storage with a last reviewed date of 02/26/2026, read in part: Policy Statement: The facility stores all medications and biologicals in locked compartments .Policy Interpretation and Implementation: Medication Storage .5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems .06/10/26 at 2:45 p.m., an interview was conducted with S1DON and S2ADON. They both confirmed the nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service. The facility failed to ensure S6HSK, S7HSK, and S8FS were competent to effectively and sanitarily perform the functions of the facility's dishwasher. This deficient practice had the potential to affect any of the 74 residents who received meals from the facility's kitchen. Findings:Review a document titled Cleaning Policies and Procedures no review date read in part: Once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry; the use of towels may re-contaminate sanitized surfaces. An interview was conducted with S10HSKS on 04/13/2026 at 8:31 a.m. S10HSKS stated that since 01/2026 the kitchen staff needed assistance. She stated some staff that work in housekeeping would help in the kitchen on their days off. S10HSKS stated S6HSK, S7HSK, and S8FS helped in the kitchen by washing dishes. S10HSKS stated she had not trained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, interviews, the facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service. This deficient practice had the potential to affect any of the 74 residents who received meals from the facility's kitchen. Findings: A review of the facility's dietary schedule for 04/01/2026 - 04/15/2026 revealed on 04/2, 04/03, 04/04, 04/05, 04/08, 04/09, 04/10, 04/11, 04/14, and 04/15 one staff was scheduled for the morning shift. On 04/13/2026 at 8:40 a.m., an observation was conducted in the kitchen. S5C and S11C were observed in the kitchen. An interview was conducted with S11C. She stated many days they had to work short. She stated staff from other departments came to the kitchen to help them. She confirmed that the staff from other departments are not trained on kitchen procedures, but they are just shown how to wash the dishes. On 04/14/2026 at 6:15 a.m., an observation of the kitchen was conducted. S5C was observed preparing breakfast for the residents.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations and interviews, the facility failed to distribute, store, and serve food in accordance with professional standards for food service safety by failing to ensure:1. The food service area remained in a sanitary condition during the meal prep process.2. The ice scoops were stored away properly to prevent or minimize the spread of foodborne illnesses.3. Residents cups were stored inverted or covered.4. Staff monitored equipment to ensure that it was functioning properly.This deficient practice had the potential to affect the 74 residents who were served food from the kitchen. Findings: Review of the facility's policy titled Ice Scoop Storage with no revision date read in part: Policy - ice scoops must be stored and maintained to prevent contamination. Ice is considered a food item and must be protected. Procedure: 1. Approved storage methods - store ice scoops in a clean holder outside the ice machine or in a clean container. 3. Cleaning and Sanitizing - clean and sanitize scoops daily or when contaminated. Storage containers must be cleaned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure the well-being of residents by failing to provide oversight of the kitchen's practices for safe food service. The deficient practice had the potential to affect the 74 residents who consumed meals prepared from the facility's kitchen. Findings:Review of a document titled Ice Scoop Storage with no revision date read in part: Policy - ice scoops must be stored and maintained to prevent contamination. Ice is considered a food item and must be protected. Procedure: 1. Approved storage methods - store ice scoops in a clean holder outside the ice machine or in a clean container. 3. Cleaning and Sanitizing - clean and sanitize scoops daily or when contaminated. Storage containers must be cleaned routinely. Review of a document titled Dishware/Utensils Storage Policy with no revision date read in part: Policy - all dishes, glassware, cups shall be properly cleaned, sanitized, dried, and stored in a manner that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure kitchen equipment was maintained in a safe operating condition by failing to ensure:A leak beneath the ice machine was reported to maintenance in a timely manner.Staff monitored equipment to ensure that it was functioning properly. Findings:1. On 04/13/2026 at 11:33 a.m., an observation of the kitchen was conducted which revealed an ice machine that had a large puddle of water pooled beneath the machine. On 04/13/2026 at 11:36 a.m., an observation and interview was conducted with S3DM. S3DM was unaware of the leak beneath the ice machine. On 04/13/2026 at 12:03 p.m., an interview was conducted with S12M. S12M stated that kitchen staff had not reported a leak beneath the ice machine to him, nor did they write it in his maintenance logbook. On 04/14/2026 at 10:50 a.m., an interview was conducted with S5C who stated that the ice machine has had a leak for at least three months. She stated she did not report this to S12M, she thought S3DM would get that taken care of. 2. On 04/13/2026 at 11:33 a.m., further observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents' right to participate in the facility's residents group, Resident Council, as evidenced by administrative staff failing to consider and act upon voiced grievances during monthly Resident Council meetings for 3 of 3 residents (#2, #6 and #16) actively involved in the facility's Resident Council. This deficient practice had the potential to affect the 60 residents who resided in the facility. Findings: Review of the facility's resident council meeting minutes from October 2024 through March2025 revealed: Dated 10/03/2024 per S17AD (Activity Director) revealed Resident #16 accepted the President position and Resident #6 accepted the [NAME] President position. New issues voiced by one of the 13 residents in attendance was to please make sure the CNAs (Certified Nursing Assistants) make sure the lifter battery is on charge correct, so they can be charged for when needed the next day. There was no evidence that the voiced concern was neither addressed nor was a rationale provided by facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain privacy and confidentiality of 4 Residents (#13, #23, #27, and #39) medical records. This deficient practice had the potential to affect all of the 60 residents in the facility. Findings: A review of the facility's policy titled, Confidentiality of Information and Personal Privacy with a last review date of 01/15/2025, read in part, Our facility will protect and safeguard resident confidentiality and personal privacy. The policy also indicated general guidelines, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Computer screens will be closed or in locked position when not in use or in the presence of a nurse or unauthorized personnel. On 04/01/2025 at 8:14 a.m., an observation on Hall W revealed that the laptop on top of Med Cart A was unattended. Further observation revealed Resident #13, #23, #27, and #39's first and last name, their picture, room number, and MRN (Medical Record Number) was visible on the laptop screen. On 04/01/2025 at 8:22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that residents received respiratory care according to professional standards of practice, the physician's order, and the comprehensive person-centered care plan for 3 (#11, #14, and #19) of 3 (#11, #14, and #19) residents investigated for respiratory care, as evidenced by failing to: 1. Ensure Resident #11's humidifier bottle was changed when it was empty, and Oxygen tubing changed weekly; 2. ensure Resident #19's oxygen nebulizer mask, nasal cannula, and suction cannula were stored in a bag when not used; and 3. date and label oxygen tubing and ensuring oxygen was delivered at the ordered rate for Resident #14. Findings: On [DATE], a review of the facility's policy titled Oxygen Administration, read in part, Policy: Oxygen shall only be administered by physician order .All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures. Prefilled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Medication carts were locked when unattended for 1 (Med Cart A and Med Cart B) out of 2 (Med Cart A and Med Cart B) medication carts reviewed; 2. Medication carts were free of loose pills for 2 (Med Cart A and Med Cart B) out of 2 (Med Cart A and Med Cart B) medication carts reviewed; 3. Medication carts were free of expired medications for 2 (Med Cart A and Med Cart B) out of 2 (Med Cart A and Med Cart B) medication carts reviewed; and 4. One Ozempic Syringe (medication that helps lower blood sugar) was stored appropriately. This deficient practice had the potential to affect all of the 60 residents in the facility. Findings: A review of the facility's policy titled, Storage of Medications with a last review date of 01/15/2025, read in part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy also indicated general…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and record review, the facility failed to maintain the kitchen in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure food items were covered in the walk in cooler; 2. Failing to ensure expired food items were removed from the dry goods storage room; 3. Failing to ensure the dishwasher reached 120 degrees Fahrenheit during the wash cycle; and 4. Failing to ensure clean dishes were not stored in the dishwashing area. This deficient practice had the potential to effect the 62 residents that received nourishment from the kitchen: Findings: Review of the facility's policy titled Food Receiving and Storage, with a last revised date of 02/13/2025, read in part; Policy Statement; Foods shall be received and stored in a manner that complies with safe food handling practices .8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated 'use by date'. Review of the facility's policy titled Cleaning Policies and Procedures, with a last reviwed date of 02/13/2025 read in part; Once utensils and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that resident or resident's RP (Responsible Party) were invited to, attended, or participated in quarterly care plan meetings for 1 (Resident #47) resident out of 28 sampled residents. Findings: Review of facility document titled admission Agreement, dated 01/15/2025 revealed in part, family members are encouraged to visit often and participate in the resident's plan of care. Each quarter the Responsible Party will be invited to attend the resident's care plan conference. Review of Resident # 47's admission Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, but were not limited to, congestive heart failure, dementia and cognitive communication deficit. Review of Resident #47's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/13/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 2, indicating Resident #47's cognition was severely impaired. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and maintenance log review, the facility failed to provide a homelike environment, by failing to address a concern regarding bed repairs for 1 (#11) of 4 (#11, #13, #27, and #260) residents investigated for environment. Findings: On 04/01/2025, a review of the facility's policy titled Resident equipment with a reviewed date of 01/14/2025, read in part, Purpose: The purpose of this policy is to ensure resident equipment is properly maintained. Procedures .2. Maintenance director will assess any repairs needed and will report any equipment that is inoperable to the nursing facility administrator. On 03/31/2025 at 10:30 a.m., an observation was made of Resident #11 in her room. She stated the button on the head of her bed had not been working for over 2 months, and she had reported it to maintenance. She stated she could not lower or lift her head making it uncomfortable to sleep. During an interview on 03/31/2025 at 10:30 a.m., S9CNA Certified Nursing Assistant), stated she worked two weeks ago and the remote wasn't picking the resident's head up and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status, for 1(#7) of 28 sampled residents. Findings: A review of Resident #7's medical records revealed an admission date of 02/14/2024 with diagnoses which included but were not limited to schizoaffective disorder. A review of Resident #7's Pre admission Screening and Assessment Resident Review (PASRR) revealed a Level 11 determination that read, The individual has a serious mental illness . A review of Resident #7's annual MDS with an Assessment Reference date of 02/12/2025, revealed the following in section A1500: Is the resident currently considered by the state level 11 PASRR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. On 04/02/2025 at 1:37 p.m., an interview and review of Resident #7's MDS was conducted with S4MDS/LPN (Minimum Data Set/Licensed Practical Nurse). She confirmed that the PASRR was incorrectly coded and did not reflect that the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident received services according to the person-centered plan of care for 1 (#14) of 28 sampled residents. Findings: Review of Resident #14's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included but were not limited to Asthma, acute respiratory failure with hypoxia, acute ischemic heart disease, obstructive sleep apnea and chronic systolic (congestive) heart failure. Review of Resident #14's care plan revealed a focus area indicating the resident was at risk for falls, r/t (related to) decrease mobility, depression, respiratory failure and history of falls. Interventions included in part, refer to therapy dept (department) as needed, and refer to restorative program as needed . Review of S19PT (Physical Therapy) notes revealed Resident #14's discharge summary for dates of services 02/28/2024- 03/08/2024 with discharge reason maximum Potential achieved. Referred for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming by failing to trim and clean a resident's fingernails for 1 (Resident #39) of 28 sampled residents. The deficient practice had the potential to affect a census of 60. Findings: A review of the facility's policy titled, Care of Fingernails/Toenails with a last review date of 02/03/2025, read in part, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy also indicated general guidelines, Nail care includes daily cleaning and regular trimming. A review of Resident #39's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Type 2 Diabetes Mellitus without Complications and Vitamin D Deficiency. A review of Resident #39's Annual MDS (Minimum Data Set) dated 02/25/2025 revealed he had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (Resident #51) out of 28 sampled residents. Findings: Review of Resident #51's admission Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, but were not limited to, dysphagia, adult failure to thrive, and cachexia. Review of Resident #51's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/20/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 0, which indicated the resident had a severe cognitive impairment. Further review revealed in Section K: Swallowing/Nutritional Status Resident #51 had a feeding tube. Review of Resident #51's Order Summary Report revealed an order dated 03/27/2025 that read: Enteral feed order every shift, Jevity 1.2 70 ml/hr (milliliters per hour) with water flushes of 100 ml (milliliters) every four hours free flushes with pump. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that a resident receiving dialysis received services consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (#260) of 1 (#260) resident receiving dialysis out of a total sample size of 28 residents. Findings: On 04/02/2025, a review of the facility's policy titled Weight Assessment and Intervention with a last reviewed date of 01/15/2025, read in part, Policy statement: Resident weights are monitored for undesirable or unintended weight loss or gain: Policy Interpretation and implementation: Weight assessment: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team or the resident's physician. Resident #260 was admitted on [DATE] with diagnoses which included but were not limited to end stage renal dialysis and dependence on renal dialysis. A review of Resident #260's physician's orders revealed an order written on 03/20/2025 which read, Weights - Daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure: 1. Resident #2 and Resident #3 were assessed for the risk of entrapment from side rails. 2. Informed consent was obtained from the resident or resident's representative prior to installation of side rails for Resident #2 and Resident #3. 3. Ongoing monitoring and supervision were provided for Resident #2's use of side rails. This deficient practice occurred for 2 (Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's policy, Physical Restraints, Side Rails, with a last review date of 01/15/2024, revealed in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure all allegations of injuries of unknown source that resulted in serious bodily injury was reported immediately, or within 2 hours of the allegation to the state survey agency for 1 (#1) out of 2 (#1 and #2) residents sampled with incidents. Findings: On 11/25/2024, a review of the facility's policy titled, Abuse Investigation and Reporting with a last revision date of 01/15/2024, read in part, Reporting: 1. All alleged violations involving abuse, neglect exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; The policy also indicated that the following information 2. An alleged violation of abuse, neflect, exploitation or mistreatment (including injuries of unknown source and misappropriation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record reviews and interviews, the facility failed to develop and implement a person centered care plan for 1(Resident #2) out of 3 (Resident#1, Resident #2, and Resident #3) sampled residents by failing to ensure that the use of side rails was included in the Plan of Care for Resident #2. Findings: A review of the facility's policy Physical Restraints, Side Rails, with a last review date of 01/15/2024, revealed in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 4.The use of side rails as an assistive device will be addressed in the resident care plan. Review of Resident #2's medical record revealed an admission date of 8/16/2023 with diagnosis including, but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Bipolar Disorder, and Major Depressive Disorder. Review of Resident #2's Plan of Care contained no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for 1 (#1) out of 3 (#1, #2, and #3) sampled residents by failing to ensure the EMAR (Electronic Medication Administration Record) was complete and/or accurately documented for Resident #1. On 11/25/2024, a review of the facility's policy titled, Charting and Documentation with a last revision date of 01/15/2024, read in part, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any change in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy also indicated that the following information is to be documented in the resident medical record: Medication administered, treatments or services performed, events, incidents or accidents involving the resident and progress toward or changed in the care plan goals and objectives. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills necessary to care for residents' needs, as identified through observation of pleasure feedings for 1 (#3) of 4 (#1, #2, #3, R1) sampled residents. Findings: Review of Resident #3's clinical record revealed an admit date of 08/01/2023, with diagnoses which included Malnutrition, Vitamin D Deficiency, Type 2 Diabetes, Chronic Kidney Disease. Resident#3 received continuous PEG (Percutaneous endoscopic Gastrostomy) tube feedings with pleasure feedings. A further review of Resident #3's clinical record revealed a Speech Therapy Discharge summary dated [DATE] that read in part . Requires cueing to utilize strategy. The summary included interventions provided: swallow treatment facilitation of liquid delivery using small controlled sips/intake, facilitation of small bites/sips (1/2 to 1/3 tsp), facilitation of body positioning to increase safety with intake, training in use of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to ensure 1 (#1) of 3 (#1, #2, and #3) sampled residents was safe to perform self-administration of medication. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine if this practice is clinically appropriate and safe. Findings: On 11/13/2024 a review of the facility's undated policy titled Self-Administration of Medications, read in part, Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Review of Resident #1's electronic health record revealed an admission date of 02/27/2024 with Diagnoses which included, but were not limited to Urinary Tract Infection,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident for 1 (#2) of 3 sampled residents. The facility failed to accommodate Resident #2's choice to refuse care. Findings: Review of the facility's policy titled Residents' Rights with a review date of 01/22/2024 read in part .Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: B. be treated with respect, kindness, and dignity H. be supported by the facility in exercising his or her rights. Review of Resident #2's clinical record revealed an admit date of 05/09/2024 with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease, Heart Failure, Peripheral Vascular Disease, Cerebrovascular Accident, and Depression. Review of Resident #2's Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records for 1 (#R1) out of 4 sampled residents. The facility had a total census of 61 residents. Findings: Review of the facility's document titled, Resident Rights with a review date of 01/22/2024, and read in part .Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: T. privacy and confidentiality. Review of the facility's document titled Security of Medication Cart with a review date of 01/15/2024, read in part the nurse must initiate the computer privacy screen when the computer is out of the nurse's view. On 11/13/2024 at 8:00 a.m., an observation of the dining room area was conducted. Further observation revealed that Medication Cart B was parked outside the dining room area. The medication cart was observed unattended and unlocked with #R1's personal information being visible for visitors/residents in the facility. On 11/13/2024 at 8:01…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's person centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 1(#1) of 3 (#1, #2, and #3) sampled residents as evidenced by Resident #1's care plan not reflecting the resident's wish to transfer to another facility. Findings: Review of Resident #1's Electronic Health Record revealed she was admitted to the facility on [DATE] with Diagnoses which included, but were not limited to Urinary Tract Infection, Chronic Kidney Disease, Schizophrenia, and Bipolar Disorder. Review of Resident #1's 5 day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/28/2024 revealed in Section Q, Participation in Assessment and Goal Setting, that her goal was to remain in the facility. Review of Resident #1's current care plan revealed an entry with onset date of 02/27/2024, I wish to remain in facility/No plans to D/C (discharge) at this time. Review of a grievance dated 10/01/2024 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure medication Carts were locked when unattended for 2 (Cart A, Cart B) of 3 (Cart A, Cart B, Cart C) medication carts observed. Findings: Review of the facility's document titled Security of Medication Cart with a review date of 01/15/2024, read in part when the medication cart is not being used, it must be locked and parked at the nurses station or inside the medication room. On 11/12/2024 at 3:00 p.m., an observation of on Hall A was conducted. Further observation revealed Medication Cart A was unlocked and unattended. S4LPN (Licensed Practical Nurse) was observed sitting in the nurses station talking on her cell phone. On 11/12/2024 at 3:01 p.m., an interview was conducted with S4LPN. S4LPN confirmed that she should have locked her medication cart prior to leaving the cart unattended. On 11/12/2024 at 3:40 p.m., an observation of Hall B was conducted. Further observation revealed Medication Cart B was against the wall near the nurse's station, unattended and unlocked. A visitor was observed in the hallway near the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and observations, the facility failed to ensure the residents call system was functioning for 1 (#1) out of 3 (#1, #2, #3) sampled residents. Findings: On 07/09/2024, a review of the facility's policy titled, Answering the Call Light, with review date of 01/01/2024, revealed in part: Purpose: the purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines .4. Be sure that the call light is plugged in and functioning at all times .6. Report all defective call lights to the nurse supervisor promptly. Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Chronic Systolic Heart Failure, Chronic Venous Insufficiency, Chronic Kidney Disease Stage 3, and Type 2 Diabetes Mellitus. A review of Resident #1's MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 06/15/2024, revealed Resident #1 had a BIMS (Brief Interview of Mental Status) score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a resident's physician was consulted when there was a change in the plan of care for 1(#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to notify Resident #1's physician that his smoking privileges were revoked, and that staff were administering a nicotine replacement that had not been ordered by a physician. This deficient practice had the potential to affect the 9 residents who smoked. Findings: Resident #1 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Anxiety disorder, Major depressive disorder, Quadriplegia and Mood disorder. A review of the Resident's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/29/2024 revealed in section C that he had a BIMS (Brief Interview for Mental Status) score of 14, indicating his cognition was intact. Section GG revealed the resident was impaired on both sides and was dependent on staff for eating, care, and transfer. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure that a resident with a qualifying mental disorder, was not admitted to the facility before a preadmission screening by the State Office of Behavioral Health (OBH) was completed or obtained for 1 (#1) of 3 (#1, #2, and #3) sampled residents investigated for a complaint. Findings: On 06/06/2024, a review of the facility's policy titled PASRR (Pre-admission Screening and Resident Review) with a revision date of 12/10/2020, read in part, Purpose: The purpose of this policy is to ensure facility is following state guidelines regarding PASRR. Resident #1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Anxiety Disorder, Unspecified Mood Disorder, and Major Depressive Disorder. A review of the resident's clinical records revealed a level 1 PASRR dated 08/17/2023. In Section 111: Mental illness, an answer of no was selected for suspected or diagnosed mental illness. Further review revealed no level 2 PASRR.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's policy and procedure, and interviews, the facility failed to develop a comprehensive person-centered care plan within 7 days of the completion of the required comprehensive assessment MDS (Minimum Data Set) for 5 (Resident #4, 12, 16, 21, and 31) out of 5 (Resident #4, 12, 16, 21, and 31). The final sample size was 31. Findings: Resident #4 Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hepatitis A Without Hepatic Coma, Type 2 Diabetes Mellitus, Chronic Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease. Review of Resident #4's Annual MDS with an ARD (Assessment Reference Data) of 03/05/2024. Further review of Resident #4's EHR (Electronic Health Record) failed to reveal a compressive person-centered care plan. Resident #12 Review of Resident #12's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to properly store and label respiratory equipment for 2 (#9 and #16) out of 2 (#9 and #16) residents investigated for respiratory care. Findings: On 04/02/2024, a review of the facility's policy, Oxygen Administration, with a last reviewed date of 01/05/2024, revealed in part, the following, Policy: . All safety precautions and care of equipment shall be performed accord to recommended State and Federal guidelines and facility procedures. Prefilled humidifier bottles and nasal cannulas/mask will be changed every week and prn (as needed). All tubing and bottles are to be labeled each week when changed. When the tubing is not being used, it should be stored properly in a zip lock bag . Essential Points: There are multiple state and federal codes that address the storage, handling, and administration of oxygen. Procedures must be adhered to assure compliance with these codes . Resident #9 Review of Resident #9's health record revealed that he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observations and record review the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice as evidenced by: 1. Failing to ensure medication was not left at Resident #31's bedside; 2. Failing to ensure medications were not left unattended on top of the medication cart; 3. Failing to ensure controlled medication was not taped back in the blister pack; 4. Failing to ensure medications were stored separately from food and labeled with the resident's name. Findings: On 04/02/2024, a review of the facility's policy, Medications Storage, with a last reviewed date of 01/05/2024, revealed in part, the following, Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: . 2. The nursing staff shall be responsible for maintaining medication storage . 9. Medications must be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment for 1 (#30) out of 2(#17, #30) residents investigated for environment, out of a total sample of 31 residents. Findings: Resident #30 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity, and Moderate Protein Calorie Malnutrition. On 04/01/2024 at 9:15 a.m., an observation was made of Resident #30's bathroom. A copper colored stain was observed from the base of the left faucet into the left side of the bathroom sink. There was also a copper colored stain around the knob on the right base of the toilet spreading outward, and a large paint blister on the wall on the left side of the toilet. Further observation revealed a moderate build-up of dust on the vent in the ceiling of the bathroom. On 04/02/2024 at 3:31 p.m., a second observation was made of the resident's bathroom. The copper colored stains remained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to develop a comprehensive plan of care for 2 (#13 and #17) out of 3 (#13, #15, #17) residents investigated for care planning out of a total sample of 31 residents, by failing to: 1. Address Resident #13 family's refusal for use of a proper positioning device. 2. Address Resident #17's limited range of motion. Findings: Resident #13. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Alzheimer's disease. Review of the resident's care plan revealed the resident used a wheelchair for mobility. On 04/01/24 9:45 a.m., the resident was observed slouched down in her high back wheelchair in the dining room. On 04/01/2024 at 11:57 a.m., S10CNA (Certified Nursing Assistant) began feeding the resident lunch at the dining room table. The resident was observed slouched down in her high back wheelchair while the CNA was feeding the resident. On 04/02/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure each resident with pressure ulcers received the necessary treatment and services to promote healing as evidenced by the staff failing to assess and provide treatment for an identified pressure ulcer for 1 (#13) out of 31 sampled residents. Findings: Resident #13. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Alzheimer's Disease. Review of the resident's Braden Risk assessment dated [DATE] revealed the resident was assessed as a high risk for pressure ulcer development. Review of the resident's weekly skin inspection on 01/15/2024 revealed the resident's skin was intact. Review of the resident's weekly skin inspection on 01/22/2024 revealed the resident's skin was not intact. Review of the resident's electronic clinical record revealed that there was no evidence that an assessment of a pressure ulcer or wound was done on 01/22/2024. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure each resident receives adequate supervision and assistance to prevent falls for 1 (#42) out of 2 (#40, #42) sampled residents investigated for falls out of a total sample of 31 residents. Findings: Resident #42. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Unspecified Dementia with other Behavioral Disturbance. Review of the resident's quarterly MDS (Minimum Data Set) dated 01/31/2024 revealed the resident's BIMS (Brief Interview Mental Status) score was 3 for severely impaired for cognition. Also, the quarterly MDS revealed the resident was coded for bed and chair alarm daily. Review of the resident's care plan revealed that it addressed falls. Bed and chair alarms were both interventions to prevent falls. On 04/02/2024 at 2:00 p.m., the resident was observed sitting up in wheelchair at dining room table. The resident was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that medications and pharmaceutical services were provided to meet the needs of 2 (#25, #31) out of a total sample of 31 residents, by failing to: 1. Ensure that Resident #25's Plavix (blood thinner) was re-ordered and administered; 2. Maintain a system to account for the usage and reconciliation of all controlled medications. Findings: On 04/03/2024 at 10:30 a.m., a review of a policy titled Pharmacy Services-Ordering Medications with a revision date of 01/05/2024, revealed in part, Purpose: To ensure all medications are ordered in a timely manner. Policy .3. Drugs and Biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than five days prior to the last dosage being administered to ensure that refills are readily available. 1. Review of Resident #25's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, but were not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain an effective infection control and prevention program by failing to perform hand hygiene before preparing medications and after removing gloves after patient contact. This deficient practice had the potential to affect the 70 residents residing in the facility. Findings: On 04/03/2024, a review of the facility's policy titled Handwashing/Hand Hygiene with a revision date of 01/05/2024, revealed in part, Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .7 .b. Before and after direct contact with residents; c. Before preparing or handling medications .m. after removing gloves. On 04/02/2024 at 7:52 a.m., S14LPN (Licensed Practical Nurse) was observed during D1. She donned a pair of gloves, drew up insulin and walked into Resident #25's room to administer the medication. S14LPN returned to the cart, removed her gloves and did not perform hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.